Chronic obstructive pulmonary disease

Exploring Human-Data Interaction in Clinical Decision-making Using Scenarios: Co-design Study

BACKGROUND

When caring for patients with chronic conditions such as chronic obstructive pulmonary disease (COPD), health care professionals (HCPs) rely on multiple data sources to make decisions. Collating and visualizing these data, for example, on clinical dashboards, holds the potential to support timely and informed decision-making. Most studies on data-supported decision-making (DSDM) technologies for health care have focused on their technical feasibility or quantitative effectiveness. Although these studies are an important contribution to the literature, they do not further our limited understanding of how HCPs engage with these technologies and how they can be designed to support specific contexts of use. To advance our knowledge in this area, we must work with HCPs to explore this space and the real-world complexities of health care work and service structures.

OBJECTIVE

This study aimed to qualitatively explore how DSDM technologies could support HCPs in their decision-making regarding COPD care. We created a scenario-based research tool called Respire, which visualizes HCPs' data needs about their patients with COPD and services. We used Respire with HCPs to uncover rich and nuanced findings about human-data interaction in this context, focusing on the real-world challenges that HCPs face when carrying out their work and making decisions.

METHODS

We engaged 9 respiratory HCPs from 2 collaborating health care organizations to design Respire. We then used Respire as a tool to investigate human-data interaction in the context of decision-making about COPD care. The study followed a co-design approach that had 3 stages and spanned 2 years. The first stage involved 5 workshops with HCPs to identify data interaction scenarios that would support their work. The second stage involved creating Respire, an interactive scenario-based web app that visualizes HCPs' data needs, incorporating feedback from HCPs. The final stage involved 11 one-to-one sessions with HCPs to use Respire, focusing on how they envisaged that it could support their work and decisions about care.

RESULTS

We found that HCPs trust data differently depending on where it came from and who recorded it, sporadic and subjective data generated by patients have value but create challenges for decision-making, and HCPs require support in interpreting and responding to new data and its use cases.

CONCLUSIONS

Our study uncovered important lessons for the design of DSDM technologies to support health care contexts. We show that although DSDM technologies have the potential to support patient care and health care delivery, important sociotechnical and human-data interaction challenges influence the design and deployment of these technologies. Exploring these considerations during the design process can ensure that DSDM technologies are designed with a holistic view of how decision-making and engagement with data occur in health care contexts.

SMAD3 rs36221701 T>C polymorphism impacts COPD susceptibility in the Kashi population

Small mother against decapentaplegic (SMAD) family member 3 (SMAD3) is well correlated with the inflammatory response of chronic obstructive pulmonary disease (COPD). A previous study indicated that the single nucleotide polymorphism (SNP) rs36221701 of SMAD3 was related to the risk of inflammatory disease. Hence, given the pathogenesis of COPD is intently associated with smoking and gene polymorphism, this study aims to analyze the relationship between SMAD3 rs36221701 and COPD susceptibility, and to explore whether the interaction is related to smoking status. We studied the association between the rs36221701 and rs34307601 of SMAD3 and COPD susceptibility, a total of 541 COPD patients and 534 controls of the Uyghur population were recruited at the First People's Hospital and the village of Kashi. The interrelation of the two SNPs with the risk of COPD was determined by calculating odds ratio (OR) and 95% confidence interval (95% CI). We found a significant association between the rs36221701 and COPD risk in the non-smoking population. TC genotype showed a significant decreased association with COPD risk (OR = 0.59, 95% CI = 0.41-0.83, P < 0.05), but CC genotype can increased the COPD risk (OR > 1, P < 0.05). In addition, COPD susceptibility was not related to the genetic variations in the rs34307601 (P > 0.05). In conclusion, we confirmed that the SMAD3 rs36221701 may be associated with COPD susceptibility in the Chinese Uyghur population, especially among non-smokers. Our data provide new light for the relationship between SMAD3 gene polymorphisms and COPD susceptibility in the Chinese Uyghur population.

Dietary Behaviour and Nutrition in Patients with COPD Treated with Long-Term Oxygen Therapy

BACKGROUND

It is the first study in Poland and one of the first in the world to assess the nutrition of patients with chronic obstructive pulmonary disease (COPD) treated with long-term oxygen therapy (LTOT).

METHODS

The study group consisted of 110 COPD patients treated with LTOT. Anthropometric measurements and spirometry were performed. The diet of patients was assessed using a 3-day nutrition diary.

RESULTS

When assessing the degree of airflow obstruction (FEV1% N) depending on the BMI in patients treated with LTOT, a statistically significant correlation was demonstrated between the BMI and the value of the FEV% N parameter (p = 0.0093). Patients with COPD with a BMI >30 had statistically significantly higher values of FEV1% N than patients with a BMI in the range of 20-24.9 (p = 0.0278). Intake of calcium, vitamins A, C, D, E and folates was lower than the recommended daily intake in more than 95% of COPD patients.

CONCLUSIONS

The diet of COPD patients treated with long-term oxygen therapy was improperly balanced, with deficiencies of important nutrients. Airflow obstruction in the respiratory tract was significantly smaller in obese patients, and greater in patients with diagnosed malnutrition.

Pneumococcal vaccines for preventing pneumonia in chronic obstructive pulmonary disease

BACKGROUND

People with chronic obstructive pulmonary disease (COPD) are at increased risk of pneumococcal disease, especially pneumonia, as well as acute exacerbations with associated morbidity and healthcare costs.

OBJECTIVES

To determine the efficacy of injectable pneumococcal vaccination for preventing pneumonia in persons with COPD.

SEARCH METHODS

We searched the Cochrane Airways COPD Trials Register and the databases CENTRAL, MEDLINE and Embase, using prespecified terms. Searches are current to November 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCT) comparing injectable pneumococcal polysaccharide vaccine (PPV) or pneumococcal conjugated vaccine (PCV) versus a control or alternative vaccine type in people with COPD.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. For meta-analyses, we subgrouped studies by vaccine type.

MAIN RESULTS

For this update, we added five studies (606 participants), meaning that the review now includes a total of 12 RCTs involving 2171 participants with COPD. Average age of participants was 66 years, male participants accounted for 67% and mean forced expiratory volume in one second (FEV1) was 1.2 L (five studies), 54% predicted (four studies). We assessed risks of selection, attrition and reporting bias as low, and risks of performance and detection bias as moderate.Compared with control, the vaccine group had a lower likelihood of developing community-acquired pneumonia (CAP) (odds ratio (OR) 0.62, 95% confidence interval (CI) 0.43 to 0.89; six studies, n = 1372; GRADE: moderate), but findings did not differ specifically for pneumococcal pneumonia (Peto OR 0.26, 95% CI 0.05 to 1.31; three studies, n = 1158; GRADE: low). The number needed to treat for an additional beneficial outcome (NNTB) (preventing one episode of CAP) was 21 (95% CI 15 to 74). Mortality from cardiorespiratory causes did not differ between vaccine and control groups (OR 1.07, 95% CI 0.69 to 1.66; three studies, n = 888; GRADE: moderate), nor did all-cause mortality differ (OR 1.00, 95% CI 0.72 to 1.40; five studies, n = 1053; GRADE: moderate). The likelihood of hospital admission for any cause, or for cardiorespiratory causes, did not differ between vaccine and control groups. Vaccination significantly reduced the likelihood of a COPD exacerbation (OR 0.60, 95% CI 0.39 to 0.93; four studies, n = 446; GRADE: moderate). The NNTB to prevent a patient from experiencing an acute exacerbation was 8 (95% CI 5 to 58). Only one study (n = 181) compared the efficacy of different vaccine types - 23-valent PPV versus 7-valent PCV - and reported no differences for CAP, all-cause mortality, hospital admission or likelihood of a COPD exacerbation, but investigators described a greater likelihood of some mild adverse effects of vaccination with PPV-23.

AUTHORS' CONCLUSIONS

Injectable polyvalent pneumococcal vaccination provides significant protection against community-acquired pneumonia, although no evidence indicates that vaccination reduced the risk of confirmed pneumococcal pneumonia, which was a relatively rare event. Vaccination reduced the likelihood of a COPD exacerbation, and moderate-quality evidence suggests the benefits of pneumococcal vaccination in people with COPD. Evidence was insufficient for comparison of different pneumococcal vaccine types.

Theoretical models for the simulation of particle deposition and tracheobronchial clearance in lungs of patients with chronic bronchitis

INTRODUCTION

Based upon theoretical models particle deposition and clearance in human respiratory systems affected by chronic bronchitis can be approximated reliably. As a consequence of those hypothetical results, optimal frame conditions (e.g., inhalation time and volume, particle properties) for inhalation therapies can be determined.

METHODS

Simulation of particle deposition was conducted by modelling a partly or fully obstructed tracheobronchial architecture. Bronchitis-induced reductions of the airway calibres were computed by application of specific scaling factors. Three different scenarios of chronic bronchitis were modelled. Brownian motion, inertial impaction, interception, and gravitational settling were assumed as main deposition forces influencing inhaled particular mass. Tracheobronchial clearance was approximated by application of generation-specific mucus velocities as well as the consideration of a slow bronchial clearance phase, whose half-time varied between 5 and 20 days.

RESULTS

Under different breathing conditions (i.e., sitting and light-work breathing) deposition of submicron and µm-sized particles is significantly enhanced within the bronchial lung region, but also alveolar deposition becomes partly enhanced. By changing the inhalation conditions target sites of therapeutic aerosols may be reached with rather high accuracy. Based on the data of this modified models, particle retention in lung airways of patients suffering from chronic bronchitis may be noticeably prolonged, with 24-hour retention values being increased by up to 50%.

DISCUSSION AND CONCLUSIONS

As exhibited by the results, particle deposition behaviour in lungs affected by chronic bronchitis differs remarkably from that in healthy lungs. These theoretical finds are mostly supported by experimental data. Further, experimental and theoretical deposition results may be used for an estimation of the grade of disease. Tracheobronchial clearance reduces its efficiency with each progress of the disease which increases the probability of bacterial infections in the airways.

[Effectiveness of influenza vaccination in preventing hospital admission due to exacerbations of chronic obstructive pulmonary disease]

INTRODUCTION

The main objective was to determine the effectiveness of influenza vaccination in preventing hospitalization due to exacerbation of chronic obstructive pulmonary disease (COPD). One secondary objective was to estimate the prevalence of vaccination, and to describe the factors that were associated with being vaccinated.

METHODS

A retrospective cohort study was conducted that included 1,323 patients diagnosed with COPD in the Health Centre of the Pla d'Urgell (Lleida, Spain). They were classified into two cohorts: cohort1, patients vaccinated against seasonal influenza (campaign 2011/12), and cohort2, non-vaccinated. The number of patients in both cohorts requiring hospital admission for exacerbation of the disease between the 12/01/2011 and the 03/15/2012 was quantified. Information about the variables of interest was recorded for each patient. A univariate and multivariate analysis was performed. The effectiveness of vaccination was calculated with the formula: E=(1-OR)×100. The ORs and their 95% confidence interval (95%CI) were determined by multivariate logistic regression models.

RESULTS

Just over half (55.3%) of the patients had been vaccinated. Vaccinated patients were older and had more associated comorbidity. At the same time, they were less hospitalized (3.0% versus 8.9%; P=.001). The crude and adjusted effectiveness of influenza vaccination in this population subgroup was 68.4% (95%CI: 47.5-81.0) and 90.8 (95%CI: 96.8-88.2), respectively.

CONCLUSION

Influenza vaccination is effective in preventing hospitalization due to acute exacerbations in COPD patients. However, immunization coverage is not as high as desired. Designing programs to increase the rate of vaccination in this population would reduce the number of hospital admissions for COPD exacerbation.

Formoterol

Inhaled formoterol is a long-acting selective beta2-adrenoceptor agonist, with an onset of action of 5 minutes postdose and a bronchodilator effect that lasts for at least 12 hours. Statistically significant and clinically relevant (>120 ml) improvements in lung function [assessed using standardized/normalized area under the forced expiratory volume in 1 second (FEV1) versus time curve (AUC FEV1)] were observed with inhaled formoterol 12 microg twice daily (the approved dosage in the US) compared with placebo in 12-week and 12-month, randomized, double-blind trials in patients with chronic obstructive pulmonary disease (COPD). The bronchodilator efficacy of formoterol 12 microg twice daily was greater than that of oral slow-release theophylline (individualized dosages) in a 12-month trial or inhaled ipratropium bromide 40 microg four times daily in a 12-week trial. Improvement in AUC FEV1 with formoterol, but not theophylline, compared with placebo was observed in patients with irreversible or poorly-reversible airflow obstruction. Formoterol also significantly improved health-related quality of life compared with ipratropium bromide or placebo and significantly reduced symptoms compared with placebo. Combination therapy with formoterol 12 microg twice daily plus ipratropium bromide 40 microg four times daily was significantly more effective than albuterol (salbutamol) 200 microg four times daily plus the same dosage of ipratropium bromide in a 3-week, randomized, double-blind, double-dummy, crossover trial. Inhaled formoterol was well tolerated in clinical trials. The incidence of investigator-determined drug-related adverse events with inhaled formoterol 12 microg twice daily was similar to that with placebo and inhaled ipratropium bromide 40 microg four times daily but lower than that with oral slow-release theophylline (individualized dosages). Importantly, there were no significant differences between formoterol and placebo or comparator drugs in cardiovascular adverse events in patients with COPD and corrected QT interval values within the normal range. In conclusion, inhaled formoterol improved lung function and health-related quality of life and reduced symptoms relative to placebo in clinical trials in patients with COPD. The drug had greater bronchodilator efficacy than oral slow-release theophylline or inhaled ipratropium bromide and showed efficacy in combination with ipratropium bromide. The adverse events profile (including cardiovascular adverse events) with formoterol was similar to that with placebo. Thus, inhaled formoterol may be considered as a first-line option for the management of bronchoconstriction in patients with COPD who require regular bronchodilator therapy for the management of symptoms.

Subacute steroid-induced paraparesis: surgical treatment of a devastating "invisible" side effect

PURPOSE

To emphasize an underestimated side effect following long-term use of steroids.

METHODS

We report on surgical treatment of two patients with serious neurologic deficits caused by epidural spinal lipoma following long-term intake of cortisone.

RESULTS

Early decompression of the spinal cord by removal of epidural lipoma was the most effective treatment in these patients with progressive symptoms.

CONCLUSION

Diagnostic work-up of such patients should include early spinal MRI resulting in surgical intervention, if indicated. Decompression of the spinal cord eventually combined with fusion is necessary.

Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease

BACKGROUND

As chronic obstructive pulmonary disease (COPD) progresses, exacerbations can occur with increasing frequency. One goal of therapy is to prevent these exacerbations, thereby reducing morbidity and associated healthcare costs. Pneumococcal vaccinations are one strategy for reducing the risk of infective exacerbations.

OBJECTIVES

To determine the safety and efficacy of pneumococcal vaccination in COPD. The primary outcomes assessed were episodes of pneumonia and acute exacerbations. Secondary outcomes of interest included hospital admissions, adverse events related to treatment, disability, change in lung function, mortality, and cost effectiveness.

SEARCH STRATEGY

We searched the Cochrane Airways Group COPD trials register and the databases CENTRAL, MEDLINE and EMBASE using pre-specified terms. The latest searches were performed in March 2010.

SELECTION CRITERIA

Randomised controlled trials assessing the effects of injectable pneumococcal vaccine in people with COPD were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and three review authors independently assessed trial quality.

MAIN RESULTS

Seven studies were identified that met the inclusion criteria for this review and were included in the 2010 review update. Two older trials used a 14-valent vaccine and five more recent trials used a 23-valent injectable vaccine.In six studies involving 1372 people, the reduction in likelihood of developing pneumonia with pneumococcal vaccination compared to control did not achieve statistical significance, the odds ratio (OR) was 0.72 (95% confidence interval (CI) 0.51 to 1.01), with moderate heterogeneity present between studies. The reduction in likelihood of acute exacerbations of COPD from two studies involving 216 people was not statistically significant (Peto OR 0.58; 95% CI 0.30 to 1.13).Of the secondary outcomes for which data were available there was no statistically significant effect for reduction in hospital admissions (two studies) or emergency department visits (one study). There was no significant reduction in pooled results from three studies involving 888 people for odds of all-cause mortality for periods up to 48 months post-vaccination (OR 0.94; 95% CI 0.67 to 1.33), or for death from cardiorespiratory causes (OR 1.07; 95% CI 0.69 to 1.66).

AUTHORS' CONCLUSIONS

The limited evidence from randomised controlled trials (RCTs) included in this review suggests that, while it is possible that injectable polyvalent pneumococcal vaccines may provide some protection against morbidity in persons with COPD, no significant effect on any of the outcomes was shown. Further large RCTs in this population would be needed to confirm effectiveness of the vaccine suggested by results from longitudinal studies.

Long-term outcomes in mild/moderate chronic obstructive pulmonary disease in the European community respiratory health survey

RATIONALE

Little is known about the long-term outcomes of individuals with mild/moderate chronic obstructive pulmonary disease (COPD) according to spirometric criteria.

OBJECTIVES

To test whether nonsmokers and asymptomatic subjects with a spirometric diagnosis of COPD have a steeper decrease in lung function and higher hospitalization rates than subjects without airway obstruction.

METHODS

A total of 5,205 subjects without asthma (20-44 years of age) from the general population, with FEV(1) >or= 50% predicted at baseline, were followed for 9 years in the frame of an international cohort study. Percent decrease in FEV(1) (DeltaFEV(1)%) and the annual hospitalization rate for respiratory causes during the follow-up were assessed for each subject.

MEASUREMENTS AND MAIN RESULTS

At baseline, 324 (6.2%) subjects had the prebronchodilator FEV(1)/FVC ratio less than the lower limit of normal (LLN-COPD), and 105 (2.0%) subjects had the same ratio less than 0.70 (modified GOLD-COPD). At follow-up, smokers with LLN-COPD (n = 205) had a greater mean DeltaFEV(1)% (1.7%; 95% confidence interval [CI], 0.8-2.7) and a higher hospitalization rate (rate ratio [RR], 2.52; 95% CI, 1.65-3.86) than normal subjects. Similarly, symptomatic subjects with LLN-COPD (n = 104) had DeltaFEV(1)% (2.0%; 95% CI, 0.8-3.3) and the hospitalization rate (RR, 4.18; 95% CI, 2.43-7.21) higher than the reference group. By contrast, nonsmokers and asymptomatic subjects with LLN-COPD had outcomes that were similar or even better than normal subjects. Among subjects with LLN-COPD, the association of symptoms with DeltaFEV(1)% varied according to smoking habits (P = 0.007); it was particularly strong in symptomatic smokers and disappeared in symptomatic nonsmokers. Similar results were found with the modified GOLD classification.

CONCLUSIONS

In relatively young populations, COPD is associated with poor long-term outcomes in smokers and in symptomatic subjects only.

Do vegetables and fruits reduce the risk of chronic obstructive pulmonary disease? A case-control study in Japan

OBJECTIVE

To investigate the relationship between vegetable and fruit consumption and the risk of chronic obstructive pulmonary disease (COPD), a case-control study was conducted in central Japan in 2006.

METHODS

A total of 278 referred patients with COPD diagnosed within the past four years and 340 community-based controls undertook spirometric measurements of respiratory function. A structured questionnaire was administered face-to-face to obtain information on demographics, lifestyle and habitual food consumption.

RESULTS

The mean vegetable and fruit intakes of cases (155.62 (SD 88.84) and 248.32 (SD 188.17) g/day) were significantly lower (p<0.01) than controls (199.14 (SD 121.41) and 304.09 (SD 253.72) g/day). A substantial reduction in COPD risk was found by increasing daily total vegetable intake, p for trend=0.037. The prevalence of breathlessness also decreased with vegetable consumption, the adjusted odds ratio being 0.49 (95% CI 0.27-0.88) for the highest versus lowest quartile of intake. However, the effects of fruit consumption were not significant. Among the nutrients contained in vegetables and fruits, vitamin A was particularly significant (p=0.008) with an estimated 52% reduction in COPD risk at the highest level of intake.

CONCLUSION

The study provided evidence of an inverse association between vegetable consumption and the risk of COPD for Japanese adults.

Soy consumption and risk of COPD and respiratory symptoms: a case-control study in Japan

BACKGROUND

To investigate the relationship between soy consumption, COPD risk and the prevalence of respiratory symptoms, a case-control study was conducted in Japan.

METHODS

A total of 278 eligible patients (244 men and 34 women), aged 50-75 years with COPD diagnosed within the past four years, were referred by respiratory physicians, while 340 controls (272 men and 68 women) were recruited from the community. All participants underwent spirometric measurements of respiratory function. Information on demographics, lifestyle characteristics and habitual food consumption was obtained using a structured questionnaire.

RESULTS

Total soy consumption was positively correlated with observed lung function measures. The mean soy intake was significantly higher among controls (59.98, SD 50.23 g/day) than cases (44.84, SD 28.5 g/day). A significant reduction in COPD risk was evident for highest versus lowest quartile of daily intake of total soybean products, with adjusted odds ratio (OR) 0.392, 95% CI 0.194-0.793, p for trend 0.001. Similar decreases in COPD risk were associated with frequent and higher intake of soy foods such as tofu and bean sprouts, whereas respiratory symptoms were inversely associated with high consumption of soy foods, especially for breathlessness (OR 0.989, 95% CI 0.982-0.996).

CONCLUSION

Increasing soy consumption was associated with a decreased risk of COPD and breathlessness.

Change in inflammation in out-patient COPD patients from stable phase to a subsequent exacerbation

Background

Inflammation increases during exacerbations of COPD, but only a few studies systematically assessed these changes. Better identification of these changes will increase our knowledge and potentially guide therapy, for instance by helping with quicker distinction of bacterially induced exacerbations from other causes.

Aim

To identify which inflammatory parameters increase during COPD exacerbations compared to stable disease, and to compare bacterial and non-bacterial exacerbations.

Methods

In 45 COPD patients (37 male/8 female, 21 current smokers, mean age 65, FEV₁ 52% predicted, pack years 38) sputum was collected during a stable phase and subsequently during an exacerbation.

Results

Sputum total cell counts (9.0 versus 7.9 × 10⁶/mL), eosinophils (0.3 versus 0.2 × 106/mL), neutrophils (6.1 versus 5.8 × 10⁶/mL), and lymphocytes (0.07 versus 0.02 × 10⁶/mL) increased significantly during an exacerbation compared to stable disease. A bacterial infection was demonstrated by culture in 8 sputum samples obtained during an exacerbation. These exacerbations had significantly increased sputum total cell and neutrophil counts, leukotriene-B4, myeloperoxidase, interleukin-8 and interleukin-6, and tumor necrosis factor-α (TNF-α) levels, and were also associated with more systemic inflammation compared to exacerbations without a bacterial infection. Sputum TNF-α level during an exacerbation had the best test characteristics to predict a bacterial infection.

Conclusion

Sputum eosinophil, neutrophil, and lymphocyte counts increase during COPD exacerbations. The increase in systemic inflammation during exacerbations seems to be limited to exacerbations caused by bacterial infections of the lower airways. Sputum TNF-α is a candidate marker for predicting airway bacterial infection.

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

COPD is a common condition, mainly related to smoking. Acute exacerbations of COPD, usually related to superimposed infection, occur commonly and systemic corticosteroids are widely used in their management in combination with other treatments including antibiotics, oxygen supplementation and bronchodilators.

OBJECTIVES

To determine the efficacy of corticosteroids, administered either parenterally or orally, on the outcomes of acute exacerbations of COPD.

SEARCH STRATEGY

Searches were carried out using the Cochrane Airways Group COPD RCT register with additional studies sought in the bibliographies of randomised controlled trials and review articles. Authors of identified randomised controlled trials were contacted for other published and unpublished studies. The last search was carried out in August 2008.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroids, administered either parenterally or orally, with appropriate placebo control. Other interventions e.g. bronchodilators and antibiotics were standardised. Clinical studies of acute asthma were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Data measured but not reported were sought from authors of included studies. Trials were combined using Review Manager for analyses.

MAIN RESULTS

Eleven studies (n=1081) fulfilled the inclusion criteria and 10 studies contributed data for analyses (n=1051). There were significantly fewer treatment failures within thirty days in patients given corticosteroid treatment, Odds Ratio (OR) 0.50; 95% confidence interval (CI) 0.36 to 0.69 and Hazard Ratio 0.78; 95% CI 0.63 to 0.97. It would have been necessary to treat 10 patients (95%CI 7 to 16) with corticosteroids to avoid one treatment failure in this time period. Duration of hospitalisation was significantly shorter with corticosteroid treatment, mean difference -1.22 days; 95% CI -2.26 to -0.18. For FEV1 there were significant treatment benefits with mean differences at the early time point (to 72 hours), 140 ml; 95% CI 90 to 190 ml and at end of treatment (up to 15 days) 80 ml; 95% confidence interval 10 to 160. There was a significant improvement in breathlessness and blood gases at both time points. There was no significant effect on mortality but an increased likelihood of an adverse event associated with corticosteroid treatment, OR 2.33; 95% CI 1.60 to 3.40. Overall one extra adverse effect occurred for every 5 people treated (95% CI 4 to 9). The risk of hyperglycaemia was significantly increased, OR 4.95; 95% CI 2.47 to 9.91.

AUTHORS' CONCLUSIONS

Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment and shortens hospital stay. It increases the rate of improvement in lung function and dyspnoea and the improvement continues during treatment, but there is a significantly increase in the risk of an adverse drug event occurring. The optimal dose and length of treatment regime needs to be better defined.

Airways inflammation and treatment during acute exacerbations of COPD

INTRODUCTION

Inflammation is a core feature of acute chronic obstructive pulmonary disease (COPD) exacerbations. It is important to focus on inflammation since it gives insight into the pathological changes causing an exacerbation, thereby possibly providing directions for future therapies which modify inflammation.

OBJECTIVES

To provide a cell-by-cell overview of the inflammatory processes during COPD exacerbations. To evaluate cell activation, and cytokine production, cellular interactions, damaging effects of inflammatory mediators to tissue, and the relation to symptoms at the onset of COPD exacerbations. To speculate on future therapeutic options to modify inflammation during COPD exacerbations.

RESULTS

During COPD exacerbations, there is increased airway wall inflammation, with pathophysiological influx of eosinophils, neutrophils, and lymphocytes. Although links have been suggested between the increase in eosinophils and lymphocytes and a viral etiology of the exacerbation, and between the increase in neutrophils and a bacterial aetiology, these increases in both inflammatory cell types are not limited to the respective aetiologies and the underlying mechanisms remain elusive.

CONCLUSION

Further research is required to fully understand the inflammatory mechanisms in the onset and development of COPD exacerbations. This might make inflammatory pathway-specific intervention possible, resulting in a more effective treatment of COPD exacerbations with fewer side effects.

Quality improvements in end of life care: insights from two collaboratives

BACKGROUND

Just a few generations ago, most people died suddenly, at any age. Now, most die of serious chronic disease, after a substantial period of disability. The care system does not serve this burgeoning population well. However, two quality improvement (QI) collaboratives sponsored by the Institute for Healthcare Improvement and the Center to Improve Care of the Dying set about making substantial improvements.

INSIGHTS GAINED

The participating organization teams in two Breakthrough Series collaboratives found it best to identify patients by asking "Would it be surprising for this patient to die in the next year? (or the next few months?)" All the teams used standard QI approaches, with an aim, measures, and changes to try in Plan-Do-Study-Act cycles. In the first collaborative, 42 (89%) of the 47 teams made important improvements in their care systems. Because of the strength of their changes, the high performance of their team, the administrative support they received, and their ability to partner with other agencies, 13 (27%) of the teams made substantial, measurable improvement during the collaborative. In the second collaborative, 29 (85%) of the 34 teams made key changes to their care system, and 16 (47%) of the teams made substantial, measurable improvement. Coordination across programs such as between a hospital and a long term care facility or hospice remained an elusive goal, and good care cannot become routine without financing and coverage reform.

CONCLUSION

Clinical providers can reliably make substantial improvements in end of life care, within a few months, and within current financing and regulation. Coordinated efforts in two Breakthrough Series produced generalizable insights.

Smoking and home oxygen therapy--a preventable public health hazard

Patients who continue to smoke while on home oxygen therapy endanger themselves, family members, neighbors, and firefighters and create an expense to society for their medical care. This phenomenon was studied in our burn center. Fourteen patients were identified prospectively during the last 2 years. All were smoking while on nasal oxygen. The 14 patients (10 males) were 45 to 87 years of age. All suffered facial burns. Only one patient had a significant burn (30% TBSA, 20% 3rd degree), but all suffered from an exacerbation of chronic obstructive pulmonary disease. Two patients gave a history of stage IV lung cancer and four patients had newly found squamous cell cancer seen on bronchoscopy. All six patients with lung cancer and one with severe chronic obstructive pulmonary disease died. Of the seven survivors, only one patient quit smoking. Total charges were $2,861,526 and total costs were $938,311. All patients had Medicare or Medicaid on admission. Hospital loss ($432,561) was incurred in those patients admitted more than 4 days whereas a profit ($33,285) was realized in patients admitted less than 4 days. These deaths and financial loss could be reduced by better testing and more precise guidelines as to which patients can safely receive home oxygen. Patients can have their saliva tested for the nicotine breakdown product of cotinine; the test takes 10 minutes. The American Burn Association, in conjunction with the American College of Chest Physicians, should address this issue and develop guidelines for physicians who order home oxygen therapy and for state departments of public health who should regulate the companies that deliver home oxygen.

Design and analysis of health products and services: An example at a specialized COPD unit

Health care demands have increased dramatically in recent decades. With the introduction of major changes in the management of health problems, health care costs have spiralled. Today, in the interests of cost control, medicine is geared towards outpatient care whenever possible.

In this process, the medical community has been obliged to adapt its traditional criteria to the dictates of national economies. Today the criteria for the organization and evaluation of the health services are based on the concepts of efficacy, effectiveness and efficiency. This has led to the emergence of a new discipline for the design and evaluation of medical service production, known as servuction, an amalgam of “service” and “production”. The organigram of a new health product should include the problems the program faces and the steps proposed to overcome these problems.

The concept of evaluation can be divided into two categories: administrative evaluation, and evaluative research. Avedis Donabedian was one of the founders of evaluative research, based on an easy-to-remember triad: structure-process-results. In the final evaluation of a new health care model, the innovations it provides must be considered.

In this article we describe the stages involved in the design of a new health product and correlate them with the types of evaluation that should be applied at each point in the process. Our discussion addresses general aspects of servuction, but also focuses on the design of a particular service, created to care for patients with severe COPD.

Daily functioning of dyspnea, self-esteem and physical self in patients with moderate COPD before, during and after a first inpatient rehabilitation program

PURPOSE

Inpatient rehabilitation improves dyspnea and increases self-esteem between admission and discharge in patients with moderate chronic obstructive pulmonary disease (COPD). Some researchers nevertheless argue that the changes may be due to nursing effects and thus that scores will decrease quickly at home after discharge. This study assessed the change in dyspnea, self-esteem and physical self mean scores and stability in patients with moderate COPD during three consecutive four-week periods: at home, during an inpatient rehabilitation program, and again at home post-discharge.

METHODS

Twenty-three consecutive patients [63.9 years (SD 6.6)] with moderate COPD [FEV1 = 55.8% (SD 13.2)] were included. The participants responded to the Physical Self Inventory and rated dyspnea using a visual analogue scale twice a day. Exercise tolerance was assessed with the six-minute walk test (6MWT) at admission and discharge.

RESULTS

6MWT performance improved between admission and discharge [452.3 m. (SD 74.0) vs. 503.3 m. (SD 80.4), p < 0.001]. Dyspnea ratings improved (p < 0.001), as did the self-esteem and physical self scores between the two home periods (p < 0.001). The group showed less instability (SD and range) in their assessments of physical self-worth at home post-discharge compared to pre-admission (p < 0.01). Before rehabilitation, the correlation coefficients between dyspnea, and self-esteem, the perceptions of physical condition and attractive body were all significant. After rehabilitation, the coefficients between dyspnea, and perceived physical condition, physical strength and sport competence were significant (p < 0.05).

CONCLUSIONS

The results suggest that a first rehabilitation program increases the mean physical self scores in patients with moderate COPD and decreases their instability; the program also improves dyspnea. However, the impact of rehabilitation was greater on specific perceptions of physical abilities than on the global self-esteem. Randomized controlled trials are needed to confirm these changes, which were probably due to rehabilitation program.

Factors influencing short-term re-admission and one-year mortality in patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVES

Fourteen day re-admission rates are deemed to be an important indicator of the quality of medical care for COPD in Taiwan. This study identified the characteristics of patients with COPD who required short-term re-admission and analysed the risk factors for 1-year mortality.

METHODS

Consecutive patients with COPD who were re-admitted to hospital within 14 days of discharge and a random computer generated selection of patients with COPD not re-admitted within 14 days of discharge were recruited to the study and their medical data collected from hospital records. Recruitment occurred over an 18-month period.

RESULTS

Fifty patients were recruited to each group. Multivariate analysis revealed statistically significant differences in oral steroid use (P = 0.013) and FEV1 (P = 0.04) between the re-admission group and non-re-admission group. Of the many variables assessed, risk of death within 1 year of discharge was significantly associated with re-admission within 14 days alone (P = 0.02; odds ratio = 15.01).

CONCLUSION

COPD patients using long-term oral corticosteroids and with a low FEV1 are at risk of re-admission with 14 days of hospital discharge, and medical care of these patients warrants much greater attention.

Transfer of care for outpatients with stable chronic obstructive pulmonary disease from respiratory care physician to respiratory nurse--a randomized controlled study

OBJECTIVES

To assess effects on patient outcomes when care for patients with stable chronic obstructive pulmonary disease (COPD) is transferred from respiratory care physician to respiratory nurse.

METHODS

A randomized controlled trial was used with a follow-up period of 9 months. Of 720 patients from the respiratory outpatient clinic of the general and teaching hospital in Alkmaar (The Netherlands), 187 were eligible for randomization and gave informed consent. Ninety-three patients received care from the nurse, and 87 received usual care. Outcomes measured were: clinical parameters, health status, self-care behaviour (including knowledge), patient satisfaction, and consultations with key care providers.

RESULTS

The respiratory nurse reported more consultations than the respiratory care physician [mean (standard deviation)]: number of consultations 3.1 (0.7) by nurse and 2.0 (0.9) by physician (p = 0.007). Patients cared for by the nurse showed worsening in mean forced vital capacity [-5.5% (13.3%) v. +2.9% (18.2%) with physician; p = 0.004], and no difference in self-assessed condition, while improvements were found for subjective knowledge (p = 0.017), self-assessed rate for coping with COPD (p = 0.045), overall satisfaction (p = 0.003), and the majority of individual indicators of satisfaction. Groups showed no differences for forced expiratory volume in 1 s, body mass index, smoking status, health status, objective knowledge, other items of self-care behaviour, and consultations with key care providers.

DISCUSSION

Assignment of care for outpatients with stable COPD to the respiratory nurse, working under a protocol, seems to be justified in terms of patient outcomes.

Vagal and sympathetic heart rate and blood pressure control in adult onset PHOX2B mutation–confirmed congenital central hypoventilation syndrome

BACKGROUND

Children with Congenital Central Hypoventilation Syndrome (CCHS) typically present as newborns with alveolar hypoventilation. With the advent of genetic testing, parents of affected children and other unrelated adults, all heterozygous for the disease-defining PHOX2B polyalanine expansion mutation with the 20/25 genotype, are being identified in adulthood. Though children with PHOX2B mutation-confirmed CCHS demonstrate ANS dysregulation, including altered heart rate and blood pressure control, it is unknown if adults with CCHS have similarly affected autonomic function in blood pressure control.

METHODS AND RESULTS

An autonomic profile of blood pressure control has been studied with recording of muscle sympathetic activity and spectral analysis of heart rate and blood pressure variability of one adult patient with alveolar hypoventilation and the 20/25 PHOX2B genotype. All parameters of heart rate variability were reduced. Cardiac baroreflex sensitivity was decreased. Sympathetic responses to Valsalva maneuver, hypoxemia, isometric exercise and cold pressor were blunted.

CONCLUSION

In summary, we found a reduced cardiac baroreflex and a blunted sympathetic mediated response in the individual with adult-onset CCHS, possibly due to dysfunction in the afferent pathway. Our results confirm that PHOX2B affects the development of the autonomic nervous system, possibly causing absence of normal maturation of carotid body and visceral sensory ganglia and leading to autonomic dysfunction in adult-onset CCHS.

Treating COPD with PDE 4 inhibitors

While the pathogenesis of chronic obstructive pulmonary disease (COPD) is incompletely understood, chronic inflammation is a major factor. In fact, the inflammatory response is abnormal, with CD8+ T-cells, CD68+ macrophages, and neutrophils predominating in the conducting airways, lung parenchyma, and pulmonary vasculature. Elevated levels of the second messenger cAMP can inhibit some inflammatory processes. Theophylline has long been used in treating asthma; it causes bronchodilation by inhibiting cyclic nucleotide phosphodiesterase (PDE), which inactivates cAMP. By inhibiting PDE, theophylline increases cAMP, inhibiting inflammation and relaxing airway smooth muscle. Rather than one PDE, there are now known to be more than 50, with differing activities, substrate preferences, and tissue distributions. Thus, the possibility exists of selectively inhibiting only the enzyme(s) in the tissue(s) of interest. PDE 4 is the primary cAMP-hydrolyzing enzyme in inflammatory and immune cells (macrophages, eosinophils, neutrophils). Inhibiting PDE 4 in these cells leads to increased cAMP levels, down-regulating the inflammatory response. Because PDE 4 is also expressed in airway smooth muscle and, in vitro, PDE 4 inhibitors relax lung smooth muscle, selective PDE 4 inhibitors are being developed for treating COPD. Clinical studies have been conducted with PDE 4 inhibitors; this review concerns those reported to date.

Injectable vaccines for preventing pneumococcal infection in patients with chronic obstructive pulmonary disease

BACKGROUND

As chronic obstructive pulmonary disease (COPD) progresses, exacerbations can occur with increasing frequency. One goal of therapy in COPD is to try and prevent these exacerbations, thereby reducing disease morbidity and associated healthcare costs. Pneumococcal vaccinations are considered to be one strategy for reducing the risk of infective exacerbations.

OBJECTIVES

To determine the safety and efficacy of pneumococcal vaccination in COPD. The primary outcome assessed was acute exacerbations. Secondary outcomes of interest included episodes of pneumonia, hospital admissions, adverse events related to treatment, disability, change in lung function, mortality, and cost effectiveness.

SEARCH STRATEGY

We searched the Cochrane Airways Group COPD trials register using pre-specified terms. We also conducted additional handsearches of conference abstracts. The last round of searches were performed in April 2006.

SELECTION CRITERIA

Only randomised controlled trials assessing the effects of injectable pneumococcal vaccine in people with COPD were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and three review authors independently assessed trial quality.

MAIN RESULTS

Although 10 studies cited in 11 publications were identified that met the inclusion criteria for this review, only four of these provided data on participants with COPD. The studies which did provide data for this review consisted of two trials using a 14-valent vaccine, and two using a 23-valent injectable vaccine. Data for the primary outcome, acute exacerbation of COPD, was available from only one of the four studies. The odds ratio of 1.43 (95% confidence interval (CI) 0.31 to 6.69) between interventions was not statistically significant. Of the secondary outcomes for which data were available and could be extracted, none reached statistical significance. Three studies provided dichotomous data for persons who developed pneumonia (OR 0.89, 95% CI 0.58 to 1.37, n = 748). Rates of hospital admissions and emergency department visits came from a single study. There was no significant reduction in the odds of all-cause mortality 1 to 48 months post-vaccination (Peto odds ratio 0.94, 95% CI 0.67 to 1.33, n = 888), or for death from cardiorespiratory causes (OR 1.07, 95% CI 0.69 to 1.66).

AUTHORS' CONCLUSIONS

There is no evidence from randomised controlled trials that injectable pneumococcal vaccination in persons with COPD has a significant impact on morbidity or mortality. Further large randomised controlled trials would be needed to ascertain if the small benefits suggested by individual studies are real.

Clinical and bacteriological efficacy in treatment of acute exacerbations of chronic bronchitis with cefditoren-pivoxil versus cefuroxime-axetil

A randomized, double-blind, double-dummy trial was performed comparing 200 mg of cefditoren-pivoxil twice daily for 5 days versus standard cefuroxime-axetil treatment (250 mg twice daily for 10 days) of Anthonisen type I or II acute exacerbations of chronic bronchitis. The modified intention-to-treat population included 541 patients. Patients were assessed during therapy, at the end of therapy (visit 3; primary evaluation time point), and at follow-up. Clinical success was obtained in 79.9% of the 264 patients included in the cefditoren-pivoxil group and in 82.7% of the 277 patients in the cefuroxime-axetil group (treatment difference, 95% confidence interval [CI]: -2.8, -9.7 to 3.6%). Treatment clinical effects were more clearly seen in sputum signs (decreasing volume and purulence from approximately 80% to approximately 10% of the patients). At the end of treatment, exploratory analysis of the per-pathogen bacteriological response showed 72.8% (of 103 isolates) in the cefditoren-pivoxil arm versus 67.0% (of 94 isolates) in the cefuroxime-axetil group (treatment difference; 95% CI: 5.8, -7.0 to 18.6%). Globally, the per-pathogen bacteriological response correlated well with clinical success: 83.5% of 164 baseline isolates from patients with a clinical success were eradicated or presumably eradicated, in contrast to only 3% of 33 isolates from patients with a clinical failure. Clinical success in patients infected with Haemophilus influenzae, the most frequent isolate, was 84% (of 50) and 82.5% (of 40) (treatment difference; 95% CI: 1.5, -14 to 17%) in the cefditoren-pivoxil versus the cefuroxime-axetil group. Although this study does not prove that either drug is better than a placebo, cefditoren-pivoxil and the standard 10-day cefuroxime-axetil course had similar point estimates of success in acute exacerbations of chronic bronchitis.

Oxygen: kill or cure? Prehospital hyperoxia in the COPD patient

High concentration oxygen therapy has long been a mainstay of prehospital treatment. Guidelines for its administration have for many years also cautioned its use with patients with chronic obstructive pulmonary disease (COPD). Successive guidelines and prehospital textbooks have advocated the use of 28% oxygen masks and re-emphasised the importance of the dangers of hyperoxia, often drawing upon the classic theory of hypoxic drive. Despite this, the reality remains that ambulance crews have tended to overoxygenate such patients. One study demonstrated that 80% of patients sampled with acute exacerbation of their COPD received oxygen in excess of 28% from the ambulance crew. Is this a worrying development or a reassuring sign that prehospital providers are rightly more concerned about the dangers of hypoxia than hyperoxia? And if the guidelines are right, then how are the hearts and minds of ambulance paramedics and technicians won?

Exacerbations de BPCO: Audit de pratique dans les services d’urgences en France

INTRODUCTION

Exacerbations of COPD are potentially serious events, the recognition and treatment of which appear to be poorly understood by both patients and doctors. The aim of this study is to describe, on the basis of two case histories, the management of exacerbations of COPD in emergency departments, to compare it with the current guidelines and to evaluate the extent of use of non-invasive ventilation in decompensated COPD.

METHODS

The study took place between February and June 2004. Two case histories describing one moderate and one severe exacerbation with respiratory failure were written by the authors of the study and submitted to an emergency physician in a university hospital and a district hospital in each region.

RESULTS

110 questionnaires were returned from 20 university hospitals and 25 district hospitals. Only 38% of the episodes were identified correctly. 20% of doctors did not regard dyspnoea as a clinical sign of an exacerbation. 22% of doctors never prescribed bronchodilators, even in severe cases. Finally, non-invasive ventilation (NIPV) was used for only 9% of the moderate and 56% of the severe exacerbations.

DISCUSSION

This study, although limited by certain factors, illustrates a number of points in need of improvement in the recognition and treatment of exacerbations of COPD in emergency departments, the use of NIPV, and the collaboration between emergency physicians, intensivists and respiratory physicians.

P-selectin glycoprotein ligand-1 (PSGL-1) is up-regulated on leucocytes from patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterized by a dysregulated recruitment of circulating leucocytes into the lung which is associated with the onset and progress of the disease. P-selectin glycoprotein ligand-1 (PSGL-1) is expressed on leucocytes and plays an essential role in primary leucocyte-endothelial cell adhesive contacts. The present study investigated if PSGL-1 is up-regulated on leucocytes of COPD patients. Peripheral blood samples were collected from COPD patients as well as controls (smoking, nonsmoking volunteers) and subjected to analysis of PSGL-1 expression on leucocytes, i.e. neutrophils, eosinophils, monocytes and lymphocytes by flow cytometry. No significant difference was observed between healthy nonsmoking and healthy smoking control subjects. In contrast, PSGL-1 expression was found to be significantly increased on the surface of all four leucocyte populations in COPD patients compared to both control groups. The finding that PSGL-1 surface expression is up-regulated on leucocytes of COPD patients as compared to leucocytes of controls suggests PSGL-1 as a potential target for anti-inflammatory treatment.

Emphysematous changes and normal variation in smokers and COPD patients using diffusion 3He MRI

INTRODUCTION

This study aims to quantify global and regional changes of diffusive motion of 3He gas within the lung, as determined by hyperpolarized 3He MR apparent diffusion coefficient (ADC) measurement, in non-smokers, smokers and chronic obstructive pulmonary disease (COPD) patients.

METHODS

Age-matched groups of six healthy non-smokers, five healthy smokers and five patients with COPD. The experiments were performed with approval from the local Research Ethics Committee. Diffusion imaging was performed following hyperpolarized 3He gas inhalation, producing ADC maps. Mean and standard deviation of the ADCs were used to compare the subject groups and assess regional variations within individuals.

RESULTS

The intra-individual standard deviation of ADC in the healthy smokers was significantly larger than that of the non-smoking group (P < 0.02). Compared to the non-smoking group, COPD patients had significantly higher mean and standard deviation of ADC (P < 0.01). The mean ADC in the anterior half of the chest was systematically higher than in the posterior half in the healthy non-smoking subject group.

DISCUSSION

This study suggests that there are regional trends in the ADC values of healthy volunteers that may have implications for the clinical interpretation of ADC values. Less homogeneous ADC values have been detected in asymptomatic smokers, indicative of damage to the distal air spaces.

Airway function and reactivity, leukocyte influx and nitric oxide after inoculation with parainfluenza-3 virus: effects of dexamethasone or rolipram

Guinea-pigs were inoculated with parainfluenza type 3 (PI3) virus (5.2 x 10(7)) or medium (125 microl each nostril). The PDE4-inhibitor, rolipram (1 mg kg(-1)), the corticosteroid, dexamethasone (20 mg kg(-1)), or vehicle were administered (i.p.) 24 h and 0.5 h before inoculation and for 4 days thereafter. Respiratory function, recorded in conscious guinea-pigs as specific airways conductance (sGaw) by whole-body plethysmography, was unaffected over 4 days by inoculation with medium or PI3. Inhaled histamine (nose-only, 1 mM, 20 s) 24 h before inoculation produced no response but 4 days after PI3 inoculation, a significant (P<0.001) bronchoconstriction occurred, indicating airway hyperreactivity (AHR). Dexamethasone or rolipram treatment inhibited the AHR. Four days after PI3- or medium-inoculation, animals underwent bronchoalveolar lavage (BAL) for total and differential (macrophages, eosinophils and neutrophils) cell counts and determination of nitric oxide (NO) as nitrite and nitrate. Compared with medium-inoculated animals, BAL fluid removed 4 days after PI3 inoculation had significantly increased macrophages, eosinophils and neutrophils. Dexamethasone or rolipram significantly (P<0.05) reduced the PI3-induced airways influx of macrophages (by 40% and 47%), eosinophils (79% and 84%) and neutrophils (58% and 61%). PI3-inoculation significantly (P<0.05) increased BALF combined NO metabolites (84.8+/-2.2 microM 100 microl(-1)), compared with medium-inoculated (56.0+/-5.8) or naive animals (45.7+/-2.0). Treating the PI3-infected guinea-pigs with dexamethasone or rolipram significantly (P<0.001) reduced the raised NO metabolites by 34% and 37%, respectively. These results support a role for steroids and PDE4-inhibitors in the management of inflammation and airways hyperreactivity arising from viral infection of the airways.

Chronic obstructive pulmonary disease is associated with enhanced bronchial expression of FGF-1, FGF-2, and FGFR-1

An important feature of chronic obstructive pulmonary disease (COPD) is airway remodelling, the molecular mechanisms of which are poorly understood. In this study, the role of fibroblast growth factors (FGF-1 and FGF-2) and their receptor, FGFR-1, was assessed in bronchial airway wall remodelling in patients with COPD (FEV1 < 75%; n = 15) and without COPD (FEV1 > 85%; n = 16). FGF-1 and FGFR-1 were immunolocalized in bronchial epithelium, airway smooth muscle (ASM), submucosal glandular epithelium, and vascular smooth muscle. Quantitative digital image analysis revealed increased cytoplasmic expression of FGF-2 in bronchial epithelium (0.35 +/- 0.03 vs 0.20 +/- 0.04, p < 0.008) and nuclear localization in ASM (p < 0.0001) in COPD patients compared with controls. Elevated levels of FGFR-1 in ASM (p < 0.005) and of FGF-1 (p < 0.04) and FGFR-1 (p < 0.001) in bronchial epithelium were observed. In cultured human ASM cells, FGF-1 and/or FGF-2 (10 ng/ml) induced cellular proliferation, as shown by [3H]thymidine incorporation and by cell number counts. Steady-state mRNA levels of FGFR-1 were elevated in human ASM cells treated with either FGF-1 or FGF-2. The increased bronchial expression of fibroblast growth factors and their receptor in patients with COPD, and the mitogenic response of human ASM cells to FGFs in vitro suggest a potential role for the FGF/FGFR-1 system in the remodelling of bronchial airways in COPD.

Functional MRI of the lung using hyperpolarized 3-helium gas

Lung imaging has traditionally relied on x-ray methods, since proton MRI is limited to some extent by low proton density in the lung parenchyma and static field inhomogeneities in the chest. The relatively recent introduction of MRI of hyperpolarized noble gases has led to a rapidly evolving field of pulmonary MRI, revealing functional information of the lungs, which were hitherto unattainable. This review article briefly describes the physical background of the technology, and subsequently focuses on its clinical applications. Four different techniques that have been used in various human investigations are discussed: ventilation distribution, ventilation dynamics, and small airway evaluation using diffusion imaging and oxygen uptake assessment.

Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease

BACKGROUND

COPD is a common condition, mainly related to smoking. The burden of the disease is increasing and it is projected to rank fifth in 2020 for the world-wide burden of disease. Acute exacerbations of COPD, usually related to superimposed infection occur commonly and systemic corticosteroids are widely used in their management in combination with other treatments including antibiotics, oxygen supplementation and bronchodilators.

OBJECTIVES

To determine the efficacy of corticosteroids, administered either parenterally or orally, on the outcome in patients with acute exacerbations of COPD.

SEARCH STRATEGY

Searches were carried out using the Cochrane Airways Group COPD RCT register with additional studies sought in the bibliographies of randomised controlled trials and review articles. Authors of identified randomised controlled trials were contacted for other published and unpublished studies. The last search was carried out in August 2004.

SELECTION CRITERIA

Randomised controlled trials comparing corticosteroids, administered either parenterally or orally, with appropriate placebo. Other interventions e.g. bronchodilators and antibiotics were standardised. Clinical studies of acute asthma were excluded.

DATA COLLECTION AND ANALYSIS

Data was extracted independently by two reviewers. Outcome data was sent to authors for verification. All trials were combined using Review Manager (version 4.2.4) for analyses.

MAIN RESULTS

Ten studies were identified that fulfilled the inclusion criteria. There were significantly fewer treatment failures within thirty days in patients given corticosteroid treatment, odds ratio 0.48; 95% confidence interval 0.34 to 0.68 and Hazard Ratio 0.78; 95% confidence interval 0.63 to 0.97. It would have been necessary to treat 9 patients (95%CI 6 to 14) with systemic corticosteroids to avoid one treatment failure in this time period. There was no significant difference in mortality. The early FEV1, up to 72 hours, showed a significant treatment benefit, weighted mean difference 140 mls (95% confidence interval 80-200 mls), although this benefit was not found for later time points. There was a significant improvement in breathlessness and blood gases between 6 - 72 hours after treatment. There was an increased likelihood of an adverse drug reaction with corticosteroid treatment, odds ratio 2.29; 95% confidence interval 1.55 to 3.38. Overall one extra adverse effect occurred for every 6 people treated (95% CI 4 to 10). The risk of hyperglycaemia was significantly increased, odds ratio 5.48; 95% confidence interval 1.58 to 18.96.

AUTHORS' CONCLUSIONS

Treatment of an exacerbation of COPD with oral or parenteral corticosteroids significantly reduces treatment failure and the need for additional medical treatment . It increases the rate of improvement in lung function and dyspnoea over the first 72 hours, but at a significantly increased risk of an adverse drug reaction.

Management of severe COPD

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality worldwide, and the burden of the disorder will continue to increase over the next 20 years despite medical intervention. Apart from smoking cessation, no approach or agent affects the rate of decline in lung function and progression of the disease. Especially in the later phase, COPD is a multicomponent disorder, and various integrated intervention strategies are needed as part of the optimum management programme. This seminar describes largely non-pharmacological interventions aimed at improving health status and function of disabled patients. Exacerbations become progressively more troublesome as baseline lung function declines, commonly necessitating hospital admission and associated with the development of acute respiratory failure.

[ANTEAB: a study of early antibiotic therapy in intensive care management of acute exacerbations of chronic obstructive lung disease]

INTRODUCTION

Intensive Care Unit (ICU) admission for acute exacerbation of chronic obstructive lung disease (COLD) is a major cause of morbidity and mortality in such patients. Although bacterial and/or viral infections are considered as the major precipitating factor, the antibiotic strategy in this setting is unclear. The potential benefit of routine antibiotic therapy in the absence of evidence of overt infection remains controversial, and has not been adequately studied in patients admitted to the ICU. To assess the benefit (or lack thereof) of routine early systemic antibiotic therapy in patients with COLD admitted to the ICU.

METHODS

This is a multicenter, randomized, double-blind controlled trial, comparing amoxicillin-clavulanic acid administered for 7 days to a placebo. Patients included are those with documented or suspected COLD, exclusive of other bronchial or lung disease, and admitted for acute exacerbation, in the absence of overt sepsis or broncho-pneumonia, and having no other organ failure. Patients recently hospitalized, having received antibiotics for > 24 h, or on long-term steroids will not be included. Co-interventions (bronchodilators, steroids) are controlled for. Patients will be administered the antibiotic or placebo within 24 hours of admission.

EXPECTED RESULTS

A 20% reduction of the duration of clinical symptoms of exacerbation is expected. To this end, 520 patients are planned to be included in 15 centers in a 2-year period. Secondary end-points are the incidence of documented infection (lower respiratory tract or other sites), antibiotic use, the proportion of patients having infection with resistant bacteria, the incidence of endotracheal intubation, the duration of stay and mortality in the ICU and the hospital.

SMAD-signaling in chronic obstructive pulmonary disease: transcriptional down-regulation of inhibitory SMAD 6 and 7 by cigarette smoke

Transforming growth factor-β1 is a potent mediator of fibrosis stimulating the secretion of extracellular matrix proteins and is involved in airway remodeling in chronic obstructive pulmonary disease (COPD). Signals from the TGF superfamily are mediated by the SMAD group of transcription factors. Here, the expression of the regulatory SMAD2, 3, the co-SMAD4 and the inhibitory SMAD6 and 7 was assessed in bronchial biopsies of COPD patients and controls by quantitative RTPCR. While SMAD2 was not expressed and SMAD3 and 4 displayed no change, the inhibitory SMAD6 and 7 were significantly downregulated in COPD. To reveal the molecular basis of tobacco smoke-induced airway remodeling and to test whether it may interfere with intracellular SMAD signaling, the airway epithelial cell line A549 was incubated with cigarette smoke extract (1% and 10%) for 48 hours, which led to down-regulation of SMAD6 and 7 at both concentrations tested. It can be concluded that TGF-β-mediated effects in COPD are influenced by a disturbed intracellular feedback mechanism of inhibitory SMADs. Also, the effects of non-volatile components in tobacco smoke may partly be regulated via a smoke-induced down-regulation of inhibitory SMADs.